New Patient Intake and History Form

Today’s Date:

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First Name

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Last Name

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Date of Birth:

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Local Pharmacy:

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Mail Order Pharmacy:

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REASON FOR COMING TO THE DOCTOR TODAY:

Reason for Today’s Visit:

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Timing/Onset: When did the symptoms first occur?

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Duration: Frequency of symptoms?

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Characterized as/Severity: Describe the severity of the symptoms/pain.

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Associated Signs and Symptoms: Are there any other symptoms associated with your problem?

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Modifying Factors: What makes the condition better and/or worse?

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Other Physicians/Specialists seen:

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PROBLEM LIST/PAST MEDICAL HISTORY:

Have you been diagnosed with any of the following (currently or in the past)?

Allergies (environmental)

Head/Neck Cancer

Hearing Loss

Obesity

Allergies (seasonal)

COPD (lung disease)

Heart Disease

Seizures

Anemia

Coronary Artery Disease

Hepatitis

Sinusitis

Anxiety

Depression

High Blood Pressure

Sleep Apnea

Arthritis

Diabetes

HIV / AIDS

Stroke

Asthma

Gastric Reflux

Irritable Bowel Syndrome

Thyroid Disorder

Cancer

Glaucoma

Migraine

Other:

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ALLERGY HISTORY:

NKDA (No Known Drug Allergies)

If Allergy noted, please list medication and reaction:

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MEDICATION HISTORY:

I am not currently taking any medications.

List any medications, vitamins, minerals and herbals that you are currently taking:

Name of Medication:

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Dosage:

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How Often:

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Name of Medication:

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Dosage:

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How Often:

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Name of Medication:

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Dosage:

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How Often:

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Name of Medication:

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Dosage:

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How Often:

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Name of Medication:

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Dosage:

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How Often:

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FAMILY HISTORY:

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PAST SURGICAL HISTORY:

Place an X next to any surgery you’ve previously had, along with the year it was done.

None

Anesthetic Complications

Adenoidectomy

Back Surgery

Breast Surgery – R / L

Cataract Surgery – R / L

Cholecystectomy

Cosmetic Surgery

Craniotomy

Ear Tubes – R / L

Ear Surgery - R / L

Endartectomy

Hypophysectomy (partial)

Hypophysectomy (total)

Hysterectomy (partial / total)

Laryngectomy (partial)

Laryngectomy (total)

Reduction of Nasal Frac

Mastoidectomy

Myringoplasty

Myringotomy – R / L

Nasal Sinusotomy

Neck Surgery

Ovary Removal - R / L

Parathyroidectomy

Reduction of Facial Frac

Rhinoplasty

Sinus Surgery

Sleep Apnea Surgery

Spinal Fusion (neck)

Tonsillectomy

Tracheostomy

Tubal Ligation

Tympanostomy

Other:

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SOCIAL HISTORY:

If smoker, how much and how often?

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If former smoker, how much did you previously smoke? How long ago did you quit?

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If you currently use tobacco or have in the past, please indicate what type (cigarettes, cigars, pipe, chew) and for how long:

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If yes, please indicate what type of beverage and how many times per week:

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If yes, please indicate what type of drug and how often:

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Describe your current sleep:

No Complaints

Daytime Drowsiness

Difficulty Falling Asleep

Early Waking

Napping

Using CPAP

If yes, please indicate what type of beverage and how many times per week:

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REVIEW OF SYSTEMS:

Please place a check mark in the box next to any of the following symptoms or problems if you have experienced them recently or have concerns about them.

General:

Loss of Appetite

Fatigue

Fever

Night Sweats

Tiredness

Weight Gain >20lbs

Weight Gain >10lbs

Skin:

Acne

Bruising

Dryness

Excessive Sweating

Itching

New Lesions

Ulcer

Rash

Hives

Cardiovascular:

Chest Pain

Shortness of Breath

Heart Attack

Low Blood Pressure

Fainting

Heart Stent

Hypertension

Gastrointestinal:

Abdominal Pain

Constipation

Diarrhea

Nausea

Vomiting

Abdominal Mass

Heartburn

Belching

Indigestion

HEENT:

Ear Discharge

Ear Infection

Ear Pain

Hearing Loss

Ringing in the Ears

Vertigo

Runny Nose

Sinusitis

Seasonal Allergies

Sneezing

Nasal Congestion

Nose Bleed

Headache

Glaucoma

Sleep Apnea

Snoring

Hoarseness

Sore Throat

Choking Sensation

Oral Ulcers

Musculoskeletal:

Joint Pain

Joint Swelling

Joint Redness

Joint Stiffness

Fibromyalgia

Upper Extremity Weakness

Neurological:

Dizziness

Fainting

Facial Paralysis

Seizures

Migraines

Stroke

Neck:

Neck Mass

Swollen Glands

Neck Pain

Neck Stiffness

Neck Swelling

Respiratory:

Cough

Difficulty Breathing

Wheezing

Bloody Sputum

Chronic Cough

Difficulty Breathing on Exertion

Snoring

Sputum Production

Wakes up from Sleep Wheezing or Short of Breath

Psychiatric:

Anxiety

Depression

PTSD

Memory Loss

Change in Sleep Pattern

Insomnia

Trouble Falling Asleep

Endocrine:

Cold Intolerance

Thyroid Problems

Hair Changes

Hematology:

Anemia

Abnormal Bleeding

Enlarged Lymph Nodes

Blood Clots

Lone Star ENT, Allergy and Aesthetic Patients

This notice is to ensure you, our patient, that proper precautions are taken by our staff to protect you from any illness that is easily transferrable from person to person while in our office. Examples of common illnesses, especially during the fall and winter months are seasonal flu, common cold viruses, and Noroviruses (stomach bug). As you well know, COVID-19 has been included as well.

In order to keep our patients safe, these precautions are taken by our office staff:

Treatment rooms are cleaned and disinfected with hospital grade cleaner between each patient.
Disinfecting of equipment used to examine patients is done by using alcohol-based cleaner or by sterilization.
Proper hand hygiene is done before patients are seen AND after patient care.

If, for any reason, you feel uncomfortable with precautions taken by our office, please reschedule your appointment for a later date.

If you agree to being treated in our office at this time, please sign your name at the bottom of this form with today’s date. Thank you for letting us participate in your care.

Lone Star ENT, Allergy and Aesthetics Care Team

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date:

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